Case Study: JaxPurpose:Analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.Scenario:Jax is a 66-year-old Caucasian female whose wife has encouraged her to seek treatment. She has never been in therapy before, and has no history of depression or anxiety. However, her alcohol use has recently been getting in the way of her marriage, and interfering with her newly-retired life. She describes drinking increasing amounts over the last year, currently consuming approximately a six-pack of beer per day. She notes that this amount “doesn’t give me the same buzz as it used to.” She denies ever experiencing “the shakes” or any other withdrawal symptoms if she skips a day of drinking.Jax comments that her wife is her biggest motivation to decrease her alcohol use. She tells Jax that she gets argumentative and irritable when she drinks, though she does not always remember these incidents. She has also fallen while intoxicated twice, causing bruises both times and hitting her head on one of the occasions.Questions:Remember to answer these questions from your textbooks and NP guidelines. At all times, explain your answers. Describe the presenting problems/issues. Is there any information that was not provided that you would need to formulate a diagnosis?Generate a primary and differential diagnosis using the DSM5 and ICD 10 codes.What physiological and psychological processes lead to substance dependence?Submission Instructions:Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
Substance Related
Disorders
• NUR 530 Psychopathology
• Week 7
• St. Thomas University
Perspectives on Substance Use
Disorders
• The nature of substance use disorders
• Abuse of psychoactive substances
• Wide-ranging physiological, psychological, and behavioral
effects
• Associated with impairment and significant costs
Substance use
• Taking moderate amounts of a substance
in a way that doesn’t interfere with
functioning
Substance intoxication
• Physical reaction to a substance (e.g.,
being drunk)
Perspectives on
Substance-Related
Disorders
Some important
terms and
distinctions
Substance abuse
• Use in a way that is dangerous or causes
substantial impairment (e.g., affecting
job or relationships)
Substance dependence
• May be defined by tolerance and withdrawal
• Sometimes defined by drug-seeking behavior
(e.g., spending too much money on substance)
Tolerance
• Needing more of a substance to get the same
effect/reduced effects from the same amount
Withdrawal
• Physical symptom reaction when substance is
discontinued after regular use
Five Main Categories of
Substances
• Depressants
• Behavioral sedation (e.g., alcohol, sedative, anxiolytic drugs)
• Stimulants
• Increase alertness and elevate mood
(e.g., cocaine, nicotine)
• Opiates
• Produce analgesia and euphoria (e.g., heroin, morphine, codeine)
• Hallucinogens
• Alter sensory perception (e.g., marijuana, LSD)
• Other drugs of abuse
• Include inhalants, anabolic steroids, medications
Substance Use Disorders in DSM-5
• Pattern of substance use leading to significant impairment and
distress
• Symptoms (need 2+ within a year)
• Taking more of the substance than intended
• Desire to cut down use
• Excessive time spent using/acquiring/recovering
• Craving for the substance
• Role disruption (e.g., can’t perform at work)
• Interpersonal problems
Substance Use Disorders in DSM-5
• Pattern of substance use leading to significant impairment and
distress
• Symptoms (need 2+ within a year)
• Reduction of important activities
• Use in physically hazardous situations (e.g., driving)
• Keep using despite causing physical or psychological
problems
• Tolerance
• Withdrawal
Substance Use Disorders in DSM-5
• DSM-5 now spells out criteria for:
• Substance intoxication for different types of substances
(e.g., alcohol, stimulants)
• Substance use disorders for different types of substances
• Withdrawal from different types of substances
The Depressants: Alcohol-Related
Disorders
• Psychological and physiological effects of alcohol
• Central nervous system depressant
• Influences several neurotransmitter systems
• Specific target is GABA
• Increases inhibitory effects—makes neural cells worse at firing
• Effects of chronic alcohol use
• Alcohol intoxication and withdrawal
• Associated brain conditions—dementia and Wernicke’s disease
• Fetal alcohol syndrome
• Developmental problems due to mother’s consumption of alcohol
when child is in the womb
Alcohol: Some Facts and Statistics
• Statistics on abuse and dependence
• Three million Americans are alcohol dependent
• 20% with alcohol problems experience spontaneous recovery
• Diversity and alcohol use
• Large variety in alcohol use statistics throughout the world
• Peru: 1 in 3 adults is dependent on alcohol
• Shanghai: leads to
desire to use again
Stimulants: Nicotine-Related
Disorders
• Effects of nicotine
• Stimulates nicotinic acetylcholine receptors in CNS
• Results in sensations of relaxation, wellness, pleasure
• Highly addictive
• Relapse rates equal to those seen with alcohol and heroin
Stimulants: Nicotine-Related
Disorders
• Nicotine users dose themselves to maintain a steady state of
nicotine
• Smoking has complex relationship to negative affect
• Appears to help improve mood in short term
• Depression occurs more in those with nicotine dependence
DSM-5 Criteria: Tobacco Use
Disorder
A problematic pattern of tobacco use leading to clinically significant
impairment or distress, as manifested by at least two of the
following, occurring within a 12-month period:
(1) Tobacco is often taken in larger amounts or over a longer
period than was intended
(2) There is a persistent desire or unsuccessful efforts to cut
down or control tobacco use
(3) A great deal of time is spent in activities necessary to
obtain or use tobacco
(4) Craving, or a strong desire or urge to use tobacco
DSM-5 Criteria: Tobacco Use
Disorder
(5) Recurrent tobacco use resulting in a failure to fulfill major
role obligations at work, school, or home
(6) Continued tobacco use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of tobacco
(7) Important social, occupational, or recreational activities
are given up or reduced because of tobacco use
(8) Recurrent tobacco use in situations in which it is physically
hazardous (e.g., smoking in bed)
DSM-5 Criteria: Tobacco Use
Disorder
(9) Tobacco use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that
is likely to have been caused or exacerbated by tobacco
(10) Tolerance, as defined by either (a) a need for markedly
increased amounts of tobacco to achieve the desired effect or
(b) a markedly diminished effect with continued use of the
same amount of tobacco
(11) Withdrawal, as manifested by either (a) the characteristic
withdrawal syndrome for tobacco or (b) tobacco (or a closely
related substance such as nicotine) is taken to relieve or avoid
withdrawal symptoms
DSM-5 Criteria for Tobacco
Withdrawal
• After several weeks of daily use, unpleasant symptoms upon
stopping or reducing:
• Insomnia, increased appetite, restlessness, trouble
concentrating, anxiety and depression, irritability
• Symptoms lead to clinically significant distress or impairment
Figure 10.4:
Relapse rates
for different
substances
© 2019 Cengage. All rights reserved.
Stimulants: Caffeine-Related
Disorders
Effects of caffeine—the “gentle” stimulant
• Used by over 90% of Americans
• Found in tea, coffee, cola drinks, and cocoa products
• Small doses elevate mood and reduce fatigue
• Regular use can result in tolerance and dependence
• Caffeine blocks the reuptake of the neurotransmitter
adenosine
Stimulants: Caffeine-Related
Disorders
DSM-5 Criteria for Caffeine Intoxication
• Recent caffeine consumption, possibly in excess
• Associated with physical symptoms including restlessness,
anxiety, insomnia, flushed face, diuresis, GI disturbance,
muscle twitching, rambling thoughts or speech, elevated or
irregular heartbeat, excitement, inexhaustibility, motor
agitation
• Symptoms cause clinically significant distress or impairment
DSM-5 Criteria: Caffeine
Intoxication
A.Recent consumption of caffeine (typically a high dose well in
excess of 250 mg)
B. Five (or more) of the following signs or symptoms developing
during, or shortly after, caffeine use:
• (1) restlessness, (2) nervousness, (3) excitement, (4)
insomnia, (5) flushed face, (6) diuresis, (7) gastrointestinal
disturbance, (8) muscle twitching, (9) rambling flow of
thought and speech, (10) tachycardia or cardiac arrhythmia,
(11) periods of inexhaustibility, (12) psychomotor agitation
DSM-5 Criteria: Caffeine
Intoxication
C.
The signs or symptoms in Criterion B cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
D.
The signs or symptoms are not attributable to another medical
condition and are not better explained by another mental
disorder, including intoxication with another substance.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC.
Opioids: An Overview
• The nature of opiates and opioids
• Opiate—natural chemical in the opium poppy with narcotic
effects
• Opioids—natural and synthetic substances with narcotic
effects
• Often referred to as analgesics
• Analgesic = painkiller
Opioids: An Overview
• Effects of opioids
• Activate body’s enkephalins and endorphins
• Low doses induce euphoria, drowsiness, and slowed
breathing
• High doses can result in death
• Withdrawal symptoms can be lasting and severe
• Mortality rates are high for opioid addicts
• High risk for HIV infection due to shared needles
DSM-5 Criteria: Opioid Use
Disorder
• A problematic pattern of opioid use leading to clinically
significant impairment or distress, with at least two of the
following, within a 12-month period:
(1) Opioids are often taken in larger amounts or over a longer
period than was intended
(2) There is a persistent desire or unsuccessful efforts to cut
down or control opioid use
(3) A great deal of time is spent in activities necessary to
obtain the opioid, use the opioid, or recover from its effects,
(4) Craving, or a strong desire or urge to use opioids
DSM-5 Criteria: Opioid Use
Disorder
(5) Recurrent opioid use resulting in a failure to fulfill major
role obligations at work, school, or home
(6) Continued opioid use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of opioids
(7) Important social, occupational, or recreational activities
are given up or reduced because of opioid use
(8) Recurrent opioid use in situations in which it is physically
hazardous
(9) Continued opioid use despite knowledge of having a
persistent physical or psychological problem that is likely to
have been caused or exacerbated by the substance
DSM-5 Criteria: Opioid Use
Disorder
(10) Tolerance, as defined by either (a) a need for markedly
increased amounts of opioids to achieve intoxication or desired
effect or (b) a markedly diminished effect with continued use of
the same amount of an opioid
(11) Withdrawal, as manifested by either (a) the characteristic
opioid withdrawal syndrome or (b) opioids are taken to relieve or
avoid withdrawal symptoms
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC.
Hallucinogens: An Overview
• Nature of hallucinogens
• Change the way the user perceives the world
• May produce
• Delusions, paranoia, hallucinations, altered sensory
perception
• Examples include marijuana, LSD
• 5–15% of people in Western countries smoke marijuana
regularly
Hallucinogens: Marijuana and LSD
• Marijuana
• Active chemical is tetrahydrocannabinol (THC)
• Symptoms – mood swings, paranoia, hallucinations
• Impairment in motivation is not uncommon
• Withdrawal and dependence are rare
• LSD and other hallucinogens
• LSD is most common form of hallucinogenic drug
• Hallucinogenic effects are much more intense than marijuana
• Tolerance is rapid and withdrawal symptoms are uncommon
• Can produce psychotic delusions and hallucinations
DSM-5 Criteria: Cannabis Use
Disorder
A problematic pattern of cannabis use leading to clinically significant
impairment or distress, as manifested by at least two of the following,
occurring within a 12-month period:
(1) Cannabis is often taken in larger amounts or over a longer
period than intended
(2) There is a persistent desire or unsuccessful efforts to cut down
or control cannabis use
(3) A great deal of time is spent in activities necessary to obtain
cannabis, use cannabis, or recover from its effects
(4) Craving, or a strong desire or urge to use cannabis
(5) Recurrent cannabis use resulting in a failure to fulfill major role
obligations at work, school, or home
DSM-5 Criteria: Cannabis Use
Disorder
(6) Continued cannabis use despite having persistent social or interpersonal
problems caused by the effects of cannabis
(7) Important social, occupational, or recreational activities are given up or
reduced because of cannabis use
(8) Recurrent cannabis use in situations in which it is physically hazardous
(9) Cannabis use is continued despite knowledge of having a persistent
physical or psychological problem that is likely to have been caused by
cannabis
(10) Tolerance, as defined by either (a) a need for markedly increased
amounts of cannabis to achieve intoxication or desired effect or (b) a
markedly diminished effect with continued use of the same amount of
cannabis
DSM-5 Criteria: Cannabis Use
Disorder
(11) Withdrawal, as manifested by either (a) the characteristic
withdrawal syndrome for cannabis or (b) cannabis (or a closely
related substance) is taken to relieve or avoid withdrawal
symptoms.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC.
DSM-5 Criteria: Other
Hallucinogen Use Disorder
A problematic pattern of hallucinogen (other than phencyclidine)
use leading to clinically significant impairment or distress, as
manifested by at least two of the following, occurring within a 12month period:
(1) The hallucinogen is often taken in larger amounts or over a
longer period than intended
(2) There is a persistent desire or unsuccessful efforts to cut
down or control hallucinogen use
(3) A great deal of time is spent in activities necessary to
obtain the hallucinogen, use the hallucinogen, or recover from
its effects
(4) Craving, or a strong desire or urge to use the hallucinogen
DSM-5 Criteria: Other
Hallucinogen Use Disorder
(5) Recurrent hallucinogen use resulting in a failure to fulfill major role
obligations at work, school, or home
(6) Continued hallucinogen use despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of the
hallucinogen
(7) Important social, occupational, or recreational activities are given up or
reduced because of hallucinogen use
(8) Recurrent hallucinogen use in situations in which it is physically
hazardous
(9) Hallucinogen use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been
caused or exacerbated by the hallucinogen
DSM-5 Criteria: Other
Hallucinogen Use Disorder
(10) Tolerance, as defined by either (a) a need for markedly
increased amounts of the hallucinogen to achieve intoxication
or desired effect or (b) a markedly diminished effect with
continued use of the same amount of the hallucinogen
Other Drugs of Abuse: Inhalants
• Nature of inhalants
• Substances found in volatile solvents
• Breathed directly into lungs
• Examples
• Spray paint, hair spray, paint thinner, gasoline, nitrous oxide
• Properties and consequences
• Rapidly absorbed
• Effects similar to alcohol intoxication
• Tolerance and prolonged symptoms of withdrawal are
common
DSM-5 Criteria: Inhalant Use
Disorder
A problematic pattern of use of a hydrocarbon-based inhalant
substance leading to clinically significant impairment or distress, as
manifested by at least two of the following, occurring within a 12month period:
(1) The inhalant substance is often taken in larger amounts or
over a longer period than was intended
(2) There is a persistent desire or unsuccessful efforts to cut
down or control use of the inhalant substance
(3) A great deal of time is spent in activities necessary to
obtain the inhalant, use it, or recover from its effects
(4) Craving, or a strong desire or urge to use the inhalant
substance
DSM-5 Criteria: Inhalant Use
Disorder
(5) Recurrent use of the inhalant substance resulting in a failure to fulfill
major role obligations at work, school, or home
(6) Continued use of the inhalant substance despite having persistent or
recurrent social or interpersonal problems caused or exacerbated by the
effects of its use
(7) Important social, occupational, or recreational activities are given up or
reduced because of use of the inhalant substance
(8) Recurrent use of the inhalant substance in situations in which it is
physically hazardous
(9) Use of the inhalant substance is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is likely to
have been caused or exacerbated by the substance
DSM-5 Criteria: Inhalant Use
Disorder
(10) Tolerance, as defined by either (a) a need for markedly
increased amounts of inhalant substance to achieve
intoxication or desired effect or (b) a markedly diminished
effect with continued use of the same amount of the inhalant
substance
Other Drugs of Abuse: Anabolic
Steroids
• Nature of anabolic-androgenic steroids
• Steroids are derived or synthesized from testosterone
• Used medicinally or to increase body mass
• Users may engage in cycling or stacking
• Do not produce a high
• Can result in long-term mood disturbances and physical
problems
Other Drugs of Abuse: Designer
Drugs
• Designer drugs
• Drugs were originally produced by pharmaceutical companies
to target diseases; then others began producing for
recreational use
• Cause drowsiness, pain relief and dissociative sensations
• Ecstasy
• BDMPEA (“nexus”)
• Ketamine (“Special K”)
Other Drugs of Abuse: Designer
Drugs
• Often heighten auditory and visual perception, sense of
taste/touch
• Becoming popular in large social recreational gatherings (e.g.,
nightclubs, raves)
• Produce tolerance and dependence
Causes of Substance-Related Disorders:
Family and Genetic Influences
• Results of family, twin, and adoption studies
• Substance abuse has a genetic component
• Example: certain genes confer risk for heroin abuse in
Latino and Black populations
• Much of the focus has been on alcoholism
• Genetic differences in alcohol metabolism > impact
which drugs are most effective for treating alcohol use
disorders
• Multiple genes are involved in substance abuse
Causes of Substance-Related
Disorders: Neurobiological Influences
Results of neurobiological research
• Drugs affect the “pleasure pathway” of the brain (i.e., the
area that is active when receiving a reward such as food)
• Believed to include dopaminergic system in areas of the
midbrain and frontal cortex
• GABA turns off reward-pleasure system
• Drugs inhibit neurotransmitters that produce
anxiety/negative affect
Causes of Substance-Related
Disorders: Psychological Dimensions
Role of positive and negative reinforcement
• Early on, drug use may be seeking a euphoric high (positive
reinforcement)
• Later, drug use will be seeking escape from withdrawal/crash
(negative reinforcement)
• Substance abuse as a means to cope with negative affect
• Self-medication, tension reduction
• Drugs offer escape from life stressors
Causes of Substance-Related
Disorders: Psychological Dimensions
• Opponent-process theory
• Why the crash after drug use fails to keep people from using:
Drugs themselves are easiest way to alleviate feelings of
withdrawal
• Cognitive factors
• Role of expectancy effects: People use drugs when they
anticipate positive effects
• Cravings
• Triggered by cues (mood, environment, availability of drug)
Causes of Substance-Related Disorders:
Social and Cultural Dimensions
• Exposure to drugs is a prerequisite for use of drugs
• Media, family, peers
• Parents and the family appear critical
• Societal views about drug abuse
• Sign of moral weakness—failure of self-control
• Sign of a disease—caused by some underlying process
Causes of Substance-Related Disorders:
Social and Cultural Dimensions
The role of cultural factors
• Influence the manifestation of substance abuse
• Some cultures expect heavy drinking at certain social
occasions (e.g., Korea)
• Cultural expectancies of substances may influence drugrelated behavior
• If drinking is thought to increase aggressiveness, people
may act in more aggressive ways after drinking
An Integrative Model of
Substance-Related Disorders
• Exposure or access to a drug is necessary, but not sufficient
• Drug use depends on:
• Social and cultural expectations
• Positive and negative reinforcement
• Genetic predisposition and biological factors
• Psychosocial stressors
Figure 10.5: An integrative model of
substance-related disorders
© 2019 Cengage. All rights reserved.
Biological Treatment of
Substance-Related Disorders
• Agonist substitution
• Safe drug with a similar chemical composition as the abused
drug
• Examples include methadone and nicotine gum or patch
• Antagonistic treatment
• Drugs that block or counteract the positive effects of
substances
• Examples include naltrexone for opiate and alcohol problems
Biological Treatment of
Substance-Related Disorders
• Aversive treatment
• Drugs that make use of substances extremely unpleasant
• Examples include antabuse and silver nitrate
• Efficacy of biological treatment
• Generally ineffective when used alone
• Used to help with withdrawal symptoms
Psychosocial Treatment of
Substance-Related Disorders
• Inpatient vs. outpatient care
• Little difference in effectiveness
• Community support programs
• Alcoholics Anonymous (AA) and related groups (e.g., NA) may
be helpful
• Balancing treatment goals
• Controlled use vs. complete abstinence
• Component treatment
• Incorporate several elements such as psychotherapy and
contingency management
Psychosocial Treatment of
Substance-Related Disorders
• Comprehensive treatment and prevention programs
• Individual and group therapy
• Aversion therapy and convert sensitization
• Contingency management
• Community reinforcement
• Relapse prevention
• Preventative efforts
• Recent shift away from education approaches
• Greater enforcement of anti-drug laws
Summary of Substance-Related
Disorders
DSM-5 substance related disorders
• Cover four classes
• Depressants, stimulants, opiates, and hallucinogens
• Diagnoses include intoxication, withdrawal and substance
use disorders
Summary of Substance-Related
Disorders
• DSM-5 substance related disorders
• Cover four classes
• Depressants, stimulants, opiates, and hallucinogens
• Diagnoses include intoxication, withdrawal and substance use disorders
• Most substances activate the dopaminergic pleasure pathway
• Psychosocial factors interact with biological influences
• Treatment of substance abuse disorders
• Often unsuccessful
• Highly motivated persons do best
• Important to use comprehensive approach
References
•
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (DSM-5®). American Psychiatric Pub.
•
Forman, R. F. (2006). Substance abuse: Clinical issues in intensive outpatient treatment.
•
Hasin, D. S., O’Brien, C. P., Auriacombe, M., Borges, G., Bucholz, K., Budney, A.,
Compton, W. M., Crowley, T., Ling, W., Petry, N. M., Schuckit, M., & Grant, B. F. (2013). DSM5 criteria for substance use disorders: Recommendations and rationale. American Journal of
Psychiatry, 170(8), 834-851. https://doi.org/10.1176/appi.ajp.2013.12060782
•
Other sex and gender issues for women related to substance use. (2020, May 28). National
Institute on Drug Abuse. https://www.drugabuse.gov/publications/researchreports/substance-use-in-women/other-sex-gender-issues-women-related-to-substanceuse

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